Assessment of Neurologic

Function

Assessment of Neurologic

Function

Function of the Nervous System

• Controls all motor, sensory, autonomic, cognitive, and behavioral activities.

Structures of the Neurologic System

• Central Nervous System– Brain and spinal cord

• Peripheral nervous system– Includes cranial and spinal nerves– Autonomic and somatic systems

• Basic functional unit—neuron

Neuron

Neurotransmitters• Communicate messages from one neuron to

another or to a specific target tissue.• Neurotransmitters can potentiate, terminate,

or modulate a specific action or can excite or inhibit a target cell.

• Many neurologic disorders are due to imbalance in neurotransmitters.

Brain

Medial View of the Brain

Bones and Sutures of the Skull

Meninges and Related Structures

Arterial Blood Supply of the Brain

Cross Section of the Spinal Cord Showing the Major Spinal Tracts

Cranial Nerves

Dermatome Distribution

Autonomic Nervous System

• Functions to regulates activities of internal organs and to maintain and restore internal homeostasis

• Sympathetic NS– “Fight or flight” responses– Main neurotransmitter is norepinephrine

• Parasympathetic NS– Controls mostly visceral functions

• Regulated by centers in the spinal cord, brainstem, and hypothalamus

Anatomy of the Autonomic Nervous System

Neurologic Assessment: Health History

• Pain• Seizures• Dizziness (abnormal sensation of imbalance or

movement) and vertigo (illusion of movement, usually rotation)

• Visual disturbances• Weakness • Abnormal sensations

Neurologic Assessment• Cerebral function; mental status, intellectual function thought content,

emotional status, perception, motor ability, and language ability– Note the impact of any neurologic impairment on lifestyle and patient

abilities and limitations • Cranial nerves

• Motor system; posture, gait, muscle tone and strength, coordination and balance, Romberg test

• Sensory system; tactile sensation, superficial pain, vibration and position sense

• Reflexes; DTRs, abdominal, and plantar (Babinski)

Techniques Eliciting Major Reflexes

Figure Used to Record Muscle Strength

Gerontological Considerations• Important to distinguish normal aging changes

from abnormal changes• Determine previous mental status for

comparison. Assess mental status carefully to distinguish delirium from dementia.

• Normal changes may include:– Losses in strength and agility; changes in gait,

posture and balance; slowed reaction times and decreased reflexes; visual and hearing alterations; deceased sense of taste and smell; dulling of tactile sensations; changes in the perception of pain; and decreased thermoregulatory ability

• Computed tomography(CT)• Positron emission tomography (PET)• Single photon emission computed tomography (SPECT)• Magnetic resonance imaging (MRI)• Cerebral angiography• Myelography• Noninvasive carotid flow studies• Transcranial doppler• Electroencephalography (EEG)• Electromyography (EMG)• Nerve conduction studies, evoked potential studies• Lumbar puncture, Queckenstedt’s test, and analysis of cerebrospinal fluid

Diagnostic Tests

Magnetic Resonance Imaging

Management of Patients With Neurologic

Dysfunction

Management of Patients With Neurologic

Dysfunction

Altered Level of Consciousness (LOC)• Level of responsiveness and consciousness is the most important indicator

of the patient's condition• LOC is a continuum from normal alertness and full cognition

(consciousness) to coma • Altered LOC is not the disorder but the result of a pathology • Coma: unconsciousness, unarousable unresponsiveness• Akinetic mutism: unresponsiveness to the environment, makes no

movement or sound but sometimes opens eyes• Persistent vegetative state: devoid of cognitive function but has sleep-

wake cycles• Locked-in syndrome: inability to move or respond except for eye

movements due to a lesion affecting the pons

Nursing Process: The Care of the Patient with Altered Level of Consciousness—Assessment

• Assess verbal response and orientation• Alertness• Motor responses • Respiratory status • Eye signs• Reflexes• Postures• Glasgow Coma Scale

Decorticate Posturing Decerebrate Posturing

Nursing Process: The Care of the Patient with Altered Level of Consciousness— Diagnoses

• Ineffective airway clearance• Risk of injury• Deficient fluid volume• Impaired oral mucosa• Risk for impaired skin integrity and impaired tissue integrity (cornea) • Ineffective thermoregulation• Impaired urinary elimination and bowel incontinence• Disturbed sensory perception• Interrupted family processes

Collaborative Problems/Potential Complications

• Respiratory distress or failure• Pneumonia• Aspiration• Pressure ulcer• Deep vein thrombosis (DVT)• Contractures

Nursing Process: The Care of the Patient with Altered Level of Consciousness— Planning

• Goals may include: – Maintenance of clear airway – Protection from injury– Attainment of fluid volume balance – Maintenance of skin integrity – Absence of corneal irritation – Effective thermoregulation – Accurate perception of environmental stimuli – Maintenance of intact family or support system – Absence of complications

Interventions

• A major nursing goal is to compensate for the patient's loss of protective reflexes and to assume responsibility for total patient care. Protection also includes maintaining the patient’s dignity and privacy.

• Maintaining an airway– Frequent monitoring of respiratory status including auscultation

of lung sounds– Positioning to promote accumulation of secretions and prevent

obstruction of upper airway—HOB elevated 30°, lateral or semiprone position

– Suctioning, oral hygiene, and CPT

Maintaining Tissue Integrity

• Assess skin frequently, especially areas with high potential for breakdown• Frequent turning; use turning schedule• Careful positioning in correct body alignment• Passive ROM• Use of splints, foam boots, trochanter rolls, and specialty beds as needed • Clean eyes with cotton balls moistened with saline• Use artificial tears as prescribed• Measures to protect eyes; use eye patches cautiously as the cornea may

contact patch• Frequent, scrupulous oral care

Interventions

• Maintaining fluid status– Assess fluid status by examining tissue turgor and mucosa, lab data, and

I&O. – Administer IVs, tube feedings, and fluids via feeding tube as required—

monitor ordered rate of IV fluids carefully. • Maintaining body temperature

– Adjust environment and cover patient appropriately.– If temperature is elevated, use minimum amount of bedding, administer

acetaminophen, use hypothermia blanket, give a cooling sponge bath, and allow fan to blow over patient to increase cooling.

– Monitor temperature frequently and use measures to prevent shivering.

Promoting Bowel and Bladder Function• Assess for urinary retention and urinary

incontinence• May require indwelling or intermittent catherization• Bladder-training program• Assess for abdominal distention, potential

constipation, and bowel incontinence • Monitor bowel movements• Promote elimination with stool softeners, glycerin

suppositories, or enemas as indicated• Diarrhea may result from infection, medications, or

hyperosmolar fluids

Sensory Stimulation and Communication

• Talk to and touch patient and encourage family to talk to and touch the patient

• Maintain normal day night pattern of activity• Orient the patient frequently• Note: When arousing from coma, a patient may

experience a period of agitation; minimize stimulation at this time

• Programs for sensory stimulation• Allow family to ventilate and provide support• Reinforce and provide and consistent information to

family • Referral to support groups and services for family

• The cranium contain: 1400g brain tissue, 75ml CSF and 75ml Blood ( these value always in state of equilibrium)

• Monro-Kellie hypothesis: because of limited space in the skull, an increase in any one of components of the skull—brain tissue, blood, and CSF—will cause a change in the volume of the others

• Compensation to maintain a normal ICP of 10–20 mm Hg is normally accomplished by shifting or displacing CSF

• With disease or injury ICP may increase• Increased ICP decreases cerebral perfusion and causes ischemia, cell death,

and (further) edema • Brain tissues may shift through the dura and result in herniation• Autoregulation: refers to the brain’s ability to change the diameter of blood

vessels to maintain cerebral blood flow• CO2 plays a role; decreased CO2 results in vasoconstriction, increased CO2

results in vasodilatation

Increased Intracranial Pressure

Brain with Intracranial Shifts

ICP and CPP• CCP (cerebral perfusion pressure) is closely

linked to ICP• CCP = MAP (mean arterial pressure) – ICP• Normal CCP is 70–100• A CCP of less than 50 results in permanent

neurolgic damage

Manifestations of Increased ICP: Early

• Changes in LOC• Any change in condition– Restlessness, confusion, increasing drowsiness,

increased respiratory effort, purposeless movements• Pupillary changes and impaired ocular movements• Weakness in one extremity or one side• Headache—constant, increasing in intensity or

aggravated by movement or straining

Manifestations of Increased ICP: Late

• Respiratory and vasomotor changes• VS: Increase in systolic blood pressure, widening of pulse pressure, and

slowing of the heart rate; pulse may fluctuate rapidly from tachycardia to bradycardia; temperature increase– Cushing’s triad: bradycardia, hypertension, bradypnea

• Projectile vomiting • Further deterioration of LOC; stupor to coma • Hemiplegia, decortication, decerebration, or flaccidity• Respiratory pattern alterations including Cheyne-Stokes breathing and arrest• Loss of brainstem reflexes—pupil, gag, corneal, and swallowing

Nursing Process: The Care of the Patient with Increased Intracranial Pressure— Assessment

• Frequent and ongoing neurologic assessment• Evaluate neurologic status as completely as

possible• Glasgow Coma Scale• Pupil checks• Assessment of selected cranial nerves• Frequent vital signs• Assessment of intracranial pressure

ICP Monitoring

Location of the foramen of Monro for calibration of ICP monitoring system

Nursing Process: The Care of the Patient with Increased Intracranial Pressure— Diagnoses

• Ineffective airway clearance• Ineffective breathing pattern• Ineffective cerebral perfusion• Deficient fluid volume related to fluid

restriction• Risk for infection related to ICP monitoring

Collaborative Problems/Potential Complications

• Brainstem herniation• Diabetes insipidus• SIADH• Infection

Nursing Process: The Care of the Patient with Increased Intracranial Pressure— Planning

• Major goals may include: – Maintenance of patent airway – Normalization of respirations – Adequate cerebral tissue perfusion – Respirations – Fluid balance – Absence of infection– Absence of complications

Interventions

• Frequent monitoring of respiratory status and lung sounds and measures to maintain a patent airway

• Position with head in neutral position and elevation of HOB 0–60° to promote venous drainage

• Avoid hip flexion, Valsalva maneuver, abdominal distention, or other stimuli that may increase ICP

• Maintain a calm, quiet atmosphere and protect patient from stress

• Monitor fluid status carefully; every hour I&O during acute phase

• Use strict aseptic technique for management of ICP monitoring system

Preoperative Care: Medical Management

• Preoperative diagnostic procedures may include CT scan, MRI, angiography, or transcranial Doppler flow studies

• Medications are usually given to reduce risk of seizures • Corticosteroids, fluid restriction, hyperosmotic agent

(mannitol), and diuretics may be used to reduce cerebral edema

• Antibiotics may be administered to reduce potential infection

• Diazepam may be used to alleviate anxiety

Preoperative Care: Nursing Management

• Obtain baseline neurologic assessment • Assess patient and family understanding of

and preparation for surgery.• Provide information, reassurance, and support

Postoperative Care• Postoperative care is aimed at detecting and

reducing cerebral edema, relieving pain, preventing seizures, monitoring ICP, and neurologic status.

• The patient may be intubated and have arterial and central venous lines.

Seizures• Abnormal episodes of motor, sensory, autonomic,

or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons

• Classification of seizures

– Partial seizures: begin in one part of the brain• Simple partial: consciousness remains intact• Complex partial: impairment of consciousness

– Generalized seizures: involve the whole brain

Specific Causes of Seizures

• Cerebrovascular disease• Hypoxemia• Fever (childhood)• Head injury• Hypertension• Central nervous system infections• Metabolic and toxic conditions• Brain tumor• Drug and alcohol withdrawal• Allergies

Plan of Care for a Patient Experiencing a Seizure

• Observation and documentation of patient signs and symptoms before, during, and after seizure

• Nursing actions during seizure for patient safety and protection

• After seizure care to prevent complications

Headache

• cephalgia• One of the most common physical complaints• Primary headache has no known organic cause and

includes migraine, tension headache, and cluster headache

• Secondary headache is a symptom with an organic cause such as a brain tumor or aneurysm

• Headache may cause significant discomfort for the person and can interfere with activities and lifestyle

Assessment of Headache

• A detailed description of the headache is obtained.• Include medication history and use.• The types of headaches manifest differently in different

persons and symptoms in one individual may also may change over time.

• Although most headaches do not indicate serious disease, persistent headaches require investigation.

• Persons undergoing a headache evaluation require a detailed history and physical assessment with neurologic exam to rule out various physical and psychological causes.

• Diagnostic testing may be used to evaluate underlying cause if there are abnormalities on the neurologic exam.

Nursing Management of Headache: Pain

• Provide individualized care and treatment• Prophylactic medications may be used for

recurrent migraines• Migraines and cluster headaches requires abortive

medications instituted as soon as possible with onset

• Provide medications as prescribed• Provide comfort measures – Quiet, dark room– Massage– Local heat for tension

Nursing Management of Headache: Teaching

• Help patient identify triggers and develop a preventive strategies and lifestyle changes for headache prevention

• Medication instruction and treatment regimen• Stress reduction techniques• Nonpharmacologic therapies• Follow-up care• Encouragement of healthy lifestyle and health

promotion activities